If current policies and procedures aren’t turning the tide against the opioid epidemic, what more should be done? Dr. McCoy speaks with Leanne Metcalfe, PhD, Executive Director of Planning and Research, Phiyen Tra, PharmD, Director of Clinical Programs, and co-host Ross Blackstone, Director of Strategic Influence, about what individuals and the public can do to help put an end to this crisis in this edition of Blue Promise. You can listen to the complete discussion in podcast form on Apple Podcasts and SoundCloud.

Additional links in the Combating the Opioid Epidemic series:

Combating the Opioid Epidemic Part 1: Policymakers attempted to combat the opioid epidemic by placing regulations on the prescribing and dispensing of opioids. How well did those rules work? We discuss in this Blue Promise.

Combating the Opioid Epidemic Part 2: The current opioid epidemic is the deadliest drug crisis in U.S. history. In this edition of Blue Promise, we take a deeper dive to understand what caused the epidemic and just how addictive opioids are.

Blue Promise is an online video blog and podcast that aims to address complicated health issues with candid conversations from subject matter experts. New editions are published regularly and are hosted by Dr. Dan McCoy, President of Blue Cross and Blue Shield of Texas.

DAN: In our previous segments we discussed some of the policies officials have put in place as a result of this crisis and how they aren't necessarily effective, so if current policies and regulations aren't working what can be done and how are we addressing the problem in Texas? Thanks for joining us for this edition of Blue Promise. I'm Dr. Dan McCoy and I'm the President of Blue Cross and Blue Shield of Texas. I'm here with Ross Blackstone.

ROSS: Thank you Dr. McCoy, we have two guests here with us today. Dr. Leanne Metcalfe is our Executive Director of Planning and Research for Blue Cross Blue Shield of Texas and Phiyen Tra is a Pharmacist and Director of our Clinical Programs. So if you guys would bear with me a little bit I'd like to share some statistics to kind of put this whole opioid conversation in perspective, specifically for Texas to localize it right? So Texas has only ranked 48th out of 50 for opioid deaths but that's a little misleading because four Texas cities are actually at the.. ranked in the top 25 cities for opioid deaths. Texarkana is actually # 10, Amarillo is 13 Odessa and Longview are all listed among the top cities in the country for opioid deaths, so this conversation really is hitting close to home. And on the economic side of things and how it affects our business environment, 25 percent of workers compensation costs are related

to prescriptions was related to opioids… 25 percent… and most people who use opioids with workers compensation for more than three months, they never even returned to work. So this is impacting our economy. The cost of opioid deaths is about $800,000 per person and in 2015 that equated to $504 billion nearly three percent of our GDP. So this is an issue

that's not just… it's not just a health crisis right, this is a business crisis, this is an economic crisis that's affecting the United States and especially us here in Texas, so with that in mind, Phiyen, we talked a little bit already about what Blue Cross and Blue Shield of Texas is doing

to address this problem can you elaborate a little bit more about what we're doing here in our state?

PHIYEN: Sure. I just say give some historical background… back in as early

as 2013, we became more aware of the opioid epidemic even before it started hitting all the news outlets and becoming more publicized and we gathered a group of leaders within our organization to come together and just brainstorm ways to help our members who are combating this type of addiction and at the time we had representation from Pharmacy, from Medical, from Special Investigations, Case Management and Behavioral Health, and we put everybody together and we said we need to come up

with a solution… it might not be the perfect solution but it's something that will help us move forward in addressing this issue and so the Controlled Substance Integration Program was born, pretty much, in 2014.

DAN: So tell us a little bit about that program and what the components are?

PHIYEN: So there are two different components within CSI. There's the Member Centric Program and the Provider Centric Program. Within the

Member Centric Program, we have ways to use our data to identify members who may basically benefit from additional interventions or outreach and we work together with medical directors to perform peer to peer conversations with the members prescribers to better understand what their regimens are,

what their plan is and then also to address any safety concerns and issues with the prescribers.

DAN: Does this actually occur early on in the use of these drugs with

a member or do you find yourself often it's… it's too late, they've actually been on these drugs for a while now?

PHIYEN: When the program first started we ran across so many different instances of situations where the member has been on high volumes of medications, they've been seeing multiple prescribers, they've essentially

been doctor shopping and then also going to different pharmacies. Now that type of behavior is very interesting to us because it's sudden red flags as to you know perhaps this person is aware of their situation that maybe they've kind of realized that, “hey I'm now trying to kind of skirt under

the radar a bit to continue using these medications because maybe I went to a previous pharmacy and maybe the pharmacists there was asking me too many questions and I got uncomfortable, so I decided to go to a different one.”

DAN: Do you think to some degree, I would think there's probably I think there's a lot of scrutiny right now on opioids so there are legitimate reasons for members to have pain do you think that they… that there's some concern when you take the prescription to the pharmacy is there an automatic thought process that is this fraudulent or not or do you think these drugs are just filled and handed out?

PHIYEN: Well I think definitely we don't want to you know shame a patient who might be going through a situation where they do need additional help and we do definitely want to support the treatment of pain and it's something that we don't want to create barriers towards.

ROSS: 87% of people who use opioids use them properly.

PHIYEN: Right yeah, so it's not that we want to create these programs as obstacles in the treatment of pain. We definitely want to use these programs as a way to coordinate better with the members, prescribers and then also talk to the members directly and offer them with additional resources to help them in their situations.

DAN: Okay so what about the provider side? So tell me a little bit

about how those interactions go with a provider community. Are they receptive usually?

PHIYEN: Yes surprisingly, so we have had some good feedback on our provider program basically what we've been doing is comparing different

prescribing habits for one prescriber against those of their peers and so in a way they see a snapshot or report card of how they're doing and how they might be an outlier in some situations and in addition to what we send out we do educate them around the state. PDMP which is the prescription drug monitoring programs that are available in which prescribers are able to log on and basically see a full view of a member's drugs that they're filling.

DAN: So I guess the issue, here's the same thing, you want providers to appropriately treat pain , but at the same time you want them to be aware of the risk of these drugs for addiction.

PHIYEN: Right.

DAN: For the most part.

ROSS: I think it's worth noting to repeat most of the providers have good intentions and when they are working with us and we're working with them but it is worth noting that there's a couple of bad apples out there. I know our company recently prosecuted one doctor who is over prescribing to his patients. Six people were killed because of his over prescriptions and he's actually now being prosecuted, so we're pursuing those and speaking about prosecutions I think it's also important to point out that it's been in the news lately that some people who are who are dying of opioids, prosecutors are going after their friends and their family members and not just the doctors, people who are enabling opioid use and sharing medications that they shouldn't be sharing, so I think that's a good takeaway. If you get a prescription, that's for you, you don't really want to be sharing it with somebody else.

LEANNE: Yeah right and the good thing there with some of the other programs that are in place and that some of our pharmacy partners are

instituting take-backs, so if you are one taking your opioid medications

you can go to those different pharmacies and just get rid of all their you know right a safe, contained, secure arena where someone else in your family won't have access to it, some you know it's akin to someone on likened it to you know having essentially a weapon in your house right you'd lock it up you keep your knives somewhere safe you know you keep things away from your kids and others that could harm themselves so

same thing with this type of with these medications keep them somewhere safe while you are using them and then when you're done you can go in and drop them off at the pharmacy.

ROSS: So what's the state doing? The state of Texas I know has been doing a lot of things, Leanne, can you enlighten us?

LEANNE: So I would definitely say that Texas and firstly I do need to give credit to the Texas legislative group because in 2015 when the hydrocodone schedule change happen and we saw scripts go down in different states but we saw the strength the dosage that morphine equivalent dose go up, the day supply go up, when we looked state-by-state Texas is actually lower

and almost flat, so their increase was slight as compared with other states. Then we saw the overall increase, so I would say that Texas was pretty good with their local interventions and their local policies and in helping ensure that we didn't have this the same level of unintended consequences in other states.

ROSS: And I know that just this past May , Texas received a grant from the federal government for $27.4 million to address opioids and the federal government expects that's gonna actually impact 14,000 people across our state.

LEANNE: Yeah and also trying to create more treatment centers because we talked about providers and supporting our providers but you know especially you know PCP settings or surgical settings, they are overwhelmed and they're not necessarily trained to manage an addict or manage someone and help titrate them off of a certain level of opioids so to have more treatment centers will also help those providers refer patients into somewhere that they can help get help as well.

DAN: But clearly that's the end state, we want to avoid right, we really don't want to get to a point where someone's addicted so there still needs to be significant education and really kind of an escalation of the proactive stance of the provider community to stand up and say there's got

to be some things done to make sure that this doesn't happen to normal routine patients that get addicted to these medications because they take them for a legitimate reason.

ROSS: And so and part of that is just it's is the onus lies on the providers, on the doctors, but it also lies on insurers and on the good community and the individual as well. I think it'd be helpful if you guys could walk us through what people should pay attention to if they go to their doctor and they might get prescribed an opioid. I mean it's not

necessarily something that you want to be terrified of because it's

gonna kill you, sometimes it's needed. We had talked earlier about how there's two different types of pain and how opioid might play into pain medication or pain treatment. Phiyen, could you kind of walk us through that what make us… helps us identify some questions maybe that we should ask whenever we approach this medication for ourselves?

PHIYEN: Right so just I'm putting myself in a member situation you know going to prescribers office, some of the questions that I would ask are you know are there any alternatives that I can use before I receive this opioid and also how long do I expect to be on this medication for? How will I be tapered off of the medication? So basically how does the

prescriber plan to decrease treatment as my pain heals and then also if there are other alternative methods of treating the pain such as you know

the massage therapy, acupuncture, over-the-counter medications, and things like that.

ROSS: Are opioids typically better for acute pain for something that's just kind of instant and might not last that long or is it better for chronic pain and something that might be a long-standing pain that you have to deal with? Is it better or worse for one or the other?

PHIYEN: I think we as Leanne mentioned in this study where we looked at patients who were prescribed opioids after surgery that's an appropriate situation, however the fact that they continued to stay on their opioids years after surgery, that's definitely

a concern

ROSS: Okay interesting conversation.. sorry go ahead.

LEANNE: Oh no, I was just going to say that before those members when they’re having that conversation with their provider as Phiyen alluded to

before it's also being open about is there something in the family history that might indicate that…

ROSS: Addiction.

LEANNE: There might be the opportunity to be addicted and also because we talked about those opioid naive patients the ones that had didn't have access to opioids before but if you aren't opiate naive and you had been

on opioids at one point in time before also being aware of that the dosage you are at it doesn't mean that the second time around you need to match it cuz that's where we do see a lot of overdoses as well the body got used to not being at such a high dose and they immediately go back to the dose level or even higher than they were at before and then they have an overdose event so you definitely want to have that open conversation to the best of your memory to the best of your history you know track things so that you don't have a situation like that as well.

DAN: Well it's been a fascinating conversation. So one thing I want to kind of talk on before we leave is the fact that we don't want to… we don't want to make another public health decision that has an adverse consequence and I think naturally when you think that drugs are over prescribed or people have too much opportunity to get something the natural assumption is we'll just turn it off right shut it all off don't make it available but I think that has some adverse consequences too, you want to talk a little bit about that?

LEANNE: And Phiyen will have some additional statistics on this as well but we find that for individuals that were in stricter programs previously

where they were identified as opioid abusers then you cut the source off they found another way to get access and in that uncontrolled environment

then you had those consequences of more overdoses or even deaths so you want to be able to look at things in a responsible way for those individuals and then also like we talked about it's ones in pain you want to be sure that they get help in a responsible way and just kind of cutting things off and ending things means that you might take other measures.

DAN: Yes let's talk about this, so one thing if you cut the drugs off right number one you could cause pain in an individual that is taking the drug for a legitimate reason.

LEANNE: Yep.

DAN: And that's not something anybody really wants to do because nobody wants to leave a patient in pain right, the second thing is they could start to drug seek because they're concerned about their pain which could result finding a pill mill or someone that prescribes a lot of medication and not properly supervised.

LEANNE: Right.

DAN: But there is the risk actually that they use illegal drugs if they can't get a legitimate source you know tell me a little bit about that.

PHIYEN: Yes we have read some articles in which patients then seek illegal drugs such as heroin for an example and…

DAN: Which is really uncontrolled.

PHIYEN: Right, right.

DAN: And really in a much higher risk of death from overdose brain.

PHIYEN: And another safety point to bring up is you know if a doctor writes an opioid prescription for you and you share it with the next person saying oh I have a medication that treats pain that creates a

very unsafe situation and I think it's very important for our members to be aware of that something in which o you think you're trying to help somebody alleviate their pain may actually put them on the course for addictions.

ROSS: 75% of opioid abusers begin with prescriptions that were not prescribed for them.

DAN: Well thank you for being here and I think what you've demonstrated is why this problem is so complex because there are issues with the providers with writing the medication the dosage of the medication the strength of the medication the addictive qualities the fact that people

legitimately have pain and the fact that there's an illegal drug market to it really creates a complex public health challenge and I really appreciate you coming here today and sharing some insight and understanding about the research that you've done and telling us a little bit more about how to help make this problem better. Thanks for being here for this episode of Blue Promise.

Telligent is an operating division of Verint Americas, Inc., an independent company that provides and hosts an online community platform for blogging and access to social media for Blue Cross and Blue Shield of Texas.

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